NHLBI seeks to reinvigorate efforts in cardiovascular health

CHICAGO -- With cardiovascular mortality rates not budging in recent years, there needs to be more concerted effort to "bend the curve," according to stakeholders convening here to discuss how to tackle the issue from several angles.

Forty years after the Bethesda Conference -- a historic meeting in 1978 to evaluate whether the 20% decline in cardiovascular mortality in the previous 10 years was real -- the current stagnation in cardiovascular disease means new questions are being asked: Why has progress come to a halt? Why are inequalities so enduring? Is it possible to achieve cardiovascular and brain health for all?

That said, "tremendous progress" has already been made: from 1958 to 2010, there was a 68% decrease in heart disease mortality, noted David Goff, MD, PhD, director of Cardiovascular Sciences at the National Heart, Lung, and Blood Institute (NHLBI) in Bethesda, Maryland, speaking at the annual meeting of the American Heart Association (AHA).

Still, cardiovascular disease continues to be a leading cause of death for people around the world.

"We're still waiting for the day we can have the 'We're #2' celebration party. It just hasn't happened," Goff said.

"The conference in 1978 was quite an extraordinary one," according to one of the original Bethesda Conference attendees, Russell Luepker, MD, MS, of the University of Minnesota in Minneapolis. People at the time attributed the improvement to a suite of factors, including mere artifact, surgical advances, the introduction of Medicare and Medicaid, and better prevention, he said.

Still, there was still something missing -- the proposed factors couldn't account for all the decrease in the heart disease epidemic, he noted.

Researchers came away from the Bethesda Conference with several key recommendations, showing a need for:

The NHLBI answered by initiating several large cohort studies, including CARDIA (1985), ARIC (1985), and MESA (1999).

From these and other studies, it is clear that the greatest rates of heart disease mortality are occurring in the Ohio and the Mississippi River valleys, and Oklahoma -- "the heartland of our country," Goff said, noting that the regional disparity is even more prominent for stroke mortality.

At the other end of the spectrum is Kaiser Permanente, where cardiovascular mortality is still on its way down, said Stephen Sidney, MD, MPH, of Kaiser Permanente in Oakland, California. "So I think part of what is happening is that young people have been impacted by obesity and diabetes. They're getting these diseases, they're getting it earlier, and they're not getting appropriately treated early."

"Kaiser Permanente has a rigorous approach to hypertension, achieving 85%-90% control rates. When people have the disease, they're given a group of medications including statins," Sidney said.

Indeed, the biggest driver of cardiovascular mortality trends is probably high blood pressure, suggested Dorairaj Prabhakaran, MD, DM, executive director of India's Centre for Chronic Disease Control and vice president of the Public Health Foundation of India.

Of the 422.7 million cases of cardiovascular disease worldwide in 2015, over three-quarters of cardiovascular deaths occured in low- to middle-income countries, he said, whereas high-income countries like the U.S. and Canada have enjoyed the steepest declines in mortality.

Yet some global trends may help relieve the cardiovascular disease burden in the hardest-hit areas.

"We're at a point where there are more cell-connected devices than people on the planet," said Michael McConnell, MD, MSEE, of Stanford Health Care in California, who suggested technology as a way to help democratize health quality around the world.

Researchers are already harnessing machine learning to interpret the huge amount of data available from physical activity tracking. For example, McConnell's group recently showed that smartphones can provide crucial information on fitness and sleep in real-world populations.

Without new approaches, it takes 17 years for basic science to take the leap to clinical practice, said Goff.

That's why in 2014, the NHLBI established the Center for Translation Research and Implementation Science with the goal of investing in research that shows how lessons learned from labs and clinical trials can best be applied to real practice. Another focus is the dilemma of health disparities, he added.

In an era where the cost of whole-genome sequencing is now under $1,000, precision public health is one particular area where there's excitement and lots of opportunity, said Donna Arnett, PhD, MSPH, of the University of Kentucky in Lexington.

The private sector apparently has a taste for personalized medicine, as the market grew from $230 billion in 2009 to $400 billion in 2015, she noted.

Nevertheless, precision public health might exacerbate existing racial and regional disparities in access to novel treatments, Arnett warned -- and it certainly won't take away environmental factors that have a negative impact on heart and brain health.

At the end of the AHA session, the moderators collected "big ideas" from audience members on how to start bringing cardiovascular deaths down again.

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